Modifier SU

Reimbursement Policy:

Effective Date:

Last Revised Date:

Purpose:

This policy provides guidelines for services appended with modifier SU for participating and nonparticipating professional providers.

Scope:

All products are included, except:

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)

COB

Professional claims with a date of service prior to 05/26/2014

SHBP claims prior to implementation date

Professional claims outside the office

Claims that do not contain Modifier SU

Facility claims

Par other

ITS Home Par

ITS Host Medicare Advantage Non PPO

ITS Host Medicare Advantage Non Par

ITS Host Medigap

ITS Host Medicaid

Labor Accounts (OON providers MPL and Flexlink)

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

Modifier SU denotes the use of the facility and equipment for a procedure performed in a physician’s office.

Policy:

The Centers for Medicare and Medicaid Services (CMS) indicates that modifier SU is not payable because CMS has established Relative Value Units (RVU) for CPT and HCPCS codes that include the costs associated with running an office, known as the practice expense RVU. In accordance with CMS, Horizon BCBSNJ shall not reimburse separately for services appended with modifier SU.

Procedure:

Deny all service lines on a professional claim that are appended with modifier SU.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit

Provider Participation Agreement

Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.

Mandated or legislative required criteria will always supersede

Policy 073_v2.0_07212015

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